401k Plan data: SILPADA DESIGNS, INC. EMPLOYEE HEALTH CARE PLAN plan

SILPADA DESIGNS, INC. EMPLOYEE HEALTH CARE PLAN 401k Plan overview

Plan Name	SILPADA DESIGNS, INC. EMPLOYEE HEALTH CARE PLAN
Plan identification number	501

SILPADA DESIGNS, INC. EMPLOYEE HEALTH CARE PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision Temporary disability (accident and sickness) Long-term disability cover Death benefits (include travel accident but not life insurance)

401k Sponsoring company profile

SILPADA DESIGNS, INC. has sponsored the creation of one or more 401k plans.

Company Name: SILPADA DESIGNS, INC.

Employer identification number (EIN): 463057216

NAIC Classification: 423940
NAIC Description: Jewelry, Watch, Precious Stone, and Precious Metal Merchant Wholesalers

Form 5500 Filing Information

Submission information for form 5500 for 401k plan SILPADA DESIGNS, INC. EMPLOYEE HEALTH CARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2016-01-01 JERRY KELLY
501 2015-01-01 SARA BASS SARA BASS 2016-07-19
501 2014-02-01 SARA BASS SARA BASS 2015-07-29
501 2013-02-01 SARA BASS SARA BASS 2014-08-28

Plan id#	Filing Submission Date	Name of Administrator	Name of Company Sponsor	Date Sponsor Signed
501	2016-01-01	JERRY KELLY
501	2015-01-01	SARA BASS	SARA BASS	2016-07-19
501	2014-02-01	SARA BASS	SARA BASS	2015-07-29
501	2013-02-01	SARA BASS	SARA BASS	2014-08-28

Plan Statistics for SILPADA DESIGNS, INC. EMPLOYEE HEALTH CARE PLAN

401k plan membership statisitcs for SILPADA DESIGNS, INC. EMPLOYEE HEALTH CARE PLAN

Measure Date Value
2016: SILPADA DESIGNS, INC. EMPLOYEE HEALTH CARE PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 197
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 0
Number of retired or separated participants receiving benefits 2016-01-01 0
Number of other retired or separated participants entitled to future benefits 2016-01-01 0
Total of all active and inactive participants 2016-01-01 0
2015: SILPADA DESIGNS, INC. EMPLOYEE HEALTH CARE PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 207
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 197
Total of all active and inactive participants 2015-01-01 197
2014: SILPADA DESIGNS, INC. EMPLOYEE HEALTH CARE PLAN 2014 401k membership
Total participants, beginning-of-year 2014-02-01 261
Total number of active participants reported on line 7a of the Form 5500 2014-02-01 207
Total of all active and inactive participants 2014-02-01 207
2013: SILPADA DESIGNS, INC. EMPLOYEE HEALTH CARE PLAN 2013 401k membership
Total participants, beginning-of-year 2013-02-01 281
Total number of active participants reported on line 7a of the Form 5500 2013-02-01 261
Total of all active and inactive participants 2013-02-01 261

Measure	Date	Value
2016: SILPADA DESIGNS, INC. EMPLOYEE HEALTH CARE PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	197
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	0
Number of retired or separated participants receiving benefits	2016-01-01	0
Number of other retired or separated participants entitled to future benefits	2016-01-01	0
Total of all active and inactive participants	2016-01-01	0
2015: SILPADA DESIGNS, INC. EMPLOYEE HEALTH CARE PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	207
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	197
Total of all active and inactive participants	2015-01-01	197
2014: SILPADA DESIGNS, INC. EMPLOYEE HEALTH CARE PLAN 2014 401k membership
Total participants, beginning-of-year	2014-02-01	261
Total number of active participants reported on line 7a of the Form 5500	2014-02-01	207
Total of all active and inactive participants	2014-02-01	207
2013: SILPADA DESIGNS, INC. EMPLOYEE HEALTH CARE PLAN 2013 401k membership
Total participants, beginning-of-year	2013-02-01	281
Total number of active participants reported on line 7a of the Form 5500	2013-02-01	261
Total of all active and inactive participants	2013-02-01	261

Form 5500 Responses for SILPADA DESIGNS, INC. EMPLOYEE HEALTH CARE PLAN

2016: SILPADA DESIGNS, INC. EMPLOYEE HEALTH CARE PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Submission has been amended	No
2016-01-01	This submission is the final filing	Yes
2016-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2016-01-01	Plan is a collectively bargained plan	No
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2015: SILPADA DESIGNS, INC. EMPLOYEE HEALTH CARE PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Submission has been amended	No
2015-01-01	This submission is the final filing	No
2015-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2015-01-01	Plan is a collectively bargained plan	No
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2014: SILPADA DESIGNS, INC. EMPLOYEE HEALTH CARE PLAN 2014 form 5500 responses
2014-02-01	Type of plan entity	Single employer plan
2014-02-01	Submission has been amended	No
2014-02-01	This submission is the final filing	No
2014-02-01	This return/report is a short plan year return/report (less than 12 months)	Yes
2014-02-01	Plan is a collectively bargained plan	No
2014-02-01	Plan funding arrangement – Insurance	Yes
2014-02-01	Plan benefit arrangement – Insurance	Yes
2013: SILPADA DESIGNS, INC. EMPLOYEE HEALTH CARE PLAN 2013 form 5500 responses
2013-02-01	Type of plan entity	Single employer plan
2013-02-01	Submission has been amended	No
2013-02-01	This submission is the final filing	No
2013-02-01	This return/report is a short plan year return/report (less than 12 months)	No
2013-02-01	Plan is a collectively bargained plan	No
2013-02-01	Plan funding arrangement – Insurance	Yes
2013-02-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

VDT 960416

Policy instance

Insurance contract or identification number	VDT 960416
Number of Individuals Covered	82
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $1,655
Total amount of fees paid to insurance company	USD $400
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $13,816
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,655
Amount paid for insurance broker fees	400
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3
Insurance broker name	THE HAYS GROUP, INC.

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

FLX 962754

Policy instance

Insurance contract or identification number	FLX 962754
Number of Individuals Covered	197
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $4,896
Total amount of fees paid to insurance company	USD $857
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $39,326
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,896
Amount paid for insurance broker fees	857
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3
Insurance broker name	THE HAYS GROUP, INC.

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

12218229

Policy instance

Insurance contract or identification number	12218229
Number of Individuals Covered	133
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $1,190
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $22,857
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,190
Insurance broker organization code?	3
Insurance broker name	THE HAYS GROUP, INC.

BLUE CROSS AND BLUE SHIELD OF KANSAS CITY (National Association of Insurance Commissioners NAIC id number: 47171 )

Policy contract number

30769000

Policy instance

Insurance contract or identification number	30769000
Number of Individuals Covered	278
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $20,928
Total amount of fees paid to insurance company	USD $22,911
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $20,928
Amount paid for insurance broker fees	22911
Additional information about fees paid to insurance broker	PROVISION OF ADMINISTRATIVE SERVICE
Insurance broker organization code?	3
Insurance broker name	THE HAYS GROUP, INC.

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

OK 964390

Policy instance

Insurance contract or identification number	OK 964390
Number of Individuals Covered	197
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $303
Total amount of fees paid to insurance company	USD $45
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $2,192
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $303
Amount paid for insurance broker fees	45
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3
Insurance broker name	THE HAYS GROUP, INC.

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

VDT 960415

Policy instance

Insurance contract or identification number	VDT 960415
Number of Individuals Covered	90
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $3,537
Total amount of fees paid to insurance company	USD $574
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $27,211
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,537
Amount paid for insurance broker fees	574
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3
Insurance broker name	THE HAYS GROUP, INC.

DELTA DENTAL OF KANSAS (National Association of Insurance Commissioners NAIC id number: 54615 )

Policy contract number

52478

Policy instance

Insurance contract or identification number	52478
Number of Individuals Covered	21
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $803
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $17,064
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $803
Insurance broker organization code?	3
Insurance broker name	THE HAYS GROUP, INC.

DELTA DENTAL OF KANSAS (National Association of Insurance Commissioners NAIC id number: 54615 )

Policy contract number

52479

Policy instance

Insurance contract or identification number	52479
Number of Individuals Covered	137
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $1,913
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $69,045
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,913
Insurance broker organization code?	3
Insurance broker name	THE HAYS GROUP, INC.

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

VDT 960416

Policy instance

Insurance contract or identification number	VDT 960416
Number of Individuals Covered	72
Insurance policy start date	2014-02-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $2,608
Total amount of fees paid to insurance company	USD $466
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $20,062
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,608
Amount paid for insurance broker fees	466
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3
Insurance broker name	THE HAYS GROUP, INC.

DELTA DENTAL OF KANSAS (National Association of Insurance Commissioners NAIC id number: 54615 )

Policy contract number

52478

Policy instance

Insurance contract or identification number	52478
Number of Individuals Covered	30
Insurance policy start date	2014-02-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $1,112
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $24,069
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,112
Insurance broker organization code?	3
Insurance broker name	THE HAYS GROUP, INC.

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

12218229

Policy instance

Insurance contract or identification number	12218229
Number of Individuals Covered	135
Insurance policy start date	2014-02-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $1,147
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $22,412
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,147
Insurance broker organization code?	3
Insurance broker name	THE HAYS GROUP, INC.

BLUE CROSS AND BLUE SHIELD OF KANSAS CITY (National Association of Insurance Commissioners NAIC id number: 47171 )

Policy contract number

30769000

Policy instance

Insurance contract or identification number	30769000
Number of Individuals Covered	317
Insurance policy start date	2014-02-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $23,829
Total amount of fees paid to insurance company	USD $22,439
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $23,829
Amount paid for insurance broker fees	22439
Additional information about fees paid to insurance broker	PROVISION OF ADMINISTRATIVE SERVICE
Insurance broker organization code?	3
Insurance broker name	THE HAYS GROUP, INC.

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

OK 964390

Policy instance

Insurance contract or identification number	OK 964390
Number of Individuals Covered	207
Insurance policy start date	2014-02-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $328
Total amount of fees paid to insurance company	USD $51
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $2,184
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $328
Amount paid for insurance broker fees	51
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3
Insurance broker name	THE HAYS GROUP, INC.

DELTA DENTAL OF KANSAS (National Association of Insurance Commissioners NAIC id number: 54615 )

Policy contract number

52479

Policy instance

Insurance contract or identification number	52479
Number of Individuals Covered	135
Insurance policy start date	2014-02-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $2,560
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $60,584
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,560
Insurance broker organization code?	3
Insurance broker name	THE HAYS GROUP, INC.

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

FLX 962754

Policy instance

Insurance contract or identification number	FLX 962754
Number of Individuals Covered	207
Insurance policy start date	2014-02-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $6,000
Total amount of fees paid to insurance company	USD $825
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $40,112
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,000
Amount paid for insurance broker fees	825
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3
Insurance broker name	THE HAYS GROUP, INC.

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

VDT 960415

Policy instance

Insurance contract or identification number	VDT 960415
Number of Individuals Covered	84
Insurance policy start date	2014-02-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $3,524
Total amount of fees paid to insurance company	USD $612
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $27,108
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,524
Amount paid for insurance broker fees	612
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3
Insurance broker name	THE HAYS GROUP, INC.

BLUE CROSS AND BLUE SHIELD OF KANSAS CITY (National Association of Insurance Commissioners NAIC id number: 47171 )

Policy contract number

30769000

Policy instance

Insurance contract or identification number	30769000
Number of Individuals Covered	378
Insurance policy start date	2013-02-01
Insurance policy end date	2014-01-31
Total amount of commissions paid to insurance broker	USD $18,149
Total amount of fees paid to insurance company	USD $29,065
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $18,149
Amount paid for insurance broker fees	29065
Additional information about fees paid to insurance broker	FEES-ADMINISTRATIVE SERVICES
Insurance broker organization code?	3
Insurance broker name	THE HAYS GROUP, INC.

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

OK 964390

Policy instance

Insurance contract or identification number	OK 964390
Number of Individuals Covered	261
Insurance policy start date	2013-02-01
Insurance policy end date	2014-01-31
Total amount of commissions paid to insurance broker	USD $353
Total amount of fees paid to insurance company	USD $47
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $2,353
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $353
Amount paid for insurance broker fees	47
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3
Insurance broker name	THE HAYS GROUP, INC.

DELTA DENTAL OF KANSAS (National Association of Insurance Commissioners NAIC id number: 54615 )

Policy contract number

52479

Policy instance

Insurance contract or identification number	52479
Number of Individuals Covered	378
Insurance policy start date	2013-02-01
Insurance policy end date	2014-01-31
Total amount of commissions paid to insurance broker	USD $1,705
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $76,172
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,705
Insurance broker organization code?	3
Insurance broker name	THE HAYS GROUP, INC.

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

12218229

Policy instance

Insurance contract or identification number	12218229
Number of Individuals Covered	173
Insurance policy start date	2013-02-01
Insurance policy end date	2014-01-31
Total amount of commissions paid to insurance broker	USD $1,378
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $29,060
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,378
Insurance broker organization code?	3
Insurance broker name	THE HAYS GROUP, INC.

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

VDT 960416

Policy instance

Insurance contract or identification number	VDT 960416
Number of Individuals Covered	96
Insurance policy start date	2013-02-01
Insurance policy end date	2014-01-31
Total amount of commissions paid to insurance broker	USD $2,759
Total amount of fees paid to insurance company	USD $404
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $21,220
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,759
Amount paid for insurance broker fees	404
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3
Insurance broker name	THE HAYS GROUP, INC.

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

FLX 962754

Policy instance

Insurance contract or identification number	FLX 962754
Number of Individuals Covered	261
Insurance policy start date	2013-02-01
Insurance policy end date	2014-01-31
Total amount of commissions paid to insurance broker	USD $5,637
Total amount of fees paid to insurance company	USD $675
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $37,580
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,637
Amount paid for insurance broker fees	675
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3
Insurance broker name	THE HAYS GROUP, INC.

DELTA DENTAL OF KANSAS (National Association of Insurance Commissioners NAIC id number: 54615 )

Policy contract number

52478

Policy instance

Insurance contract or identification number	52478
Number of Individuals Covered	90
Insurance policy start date	2013-02-01
Insurance policy end date	2014-01-31
Total amount of commissions paid to insurance broker	USD $841
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $24,702
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $841
Insurance broker organization code?	3
Insurance broker name	THE HAYS GROUP, INC.

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

VDT 960415

Policy instance

Insurance contract or identification number	VDT 960415
Number of Individuals Covered	108
Insurance policy start date	2013-02-01
Insurance policy end date	2014-01-31
Total amount of commissions paid to insurance broker	USD $3,644
Total amount of fees paid to insurance company	USD $536
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $28,027
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,644
Amount paid for insurance broker fees	536
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3
Insurance broker name	THE HAYS GROUP, INC.

Potentially related plans

SILPADA DESIGNS, INC. GROUP HEALTH CARE PLAN [EIN = 481150997]

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Company Name:	SILPADA DESIGNS, INC.
Employer identification number (EIN):	463057216
NAIC Classification:	423940
NAIC Description:	Jewelry, Watch, Precious Stone, and Precious Metal Merchant Wholesalers